1. health and fitness
2. disease
3. diabetes

REVIEW
CME
CREDIT
EDUCATIONAL OBJECTIVE: Readers will recognize the symptoms of small fiber neuropathy, list its causes,
and formulate a plan for treating it
JINNY TAVEE, MD
Neuromuscular Disease Center, Neurological Institute, Cleveland Clinic
LAN ZHOU, MD, PhD
Director, Cleveland Clinic Cutaneous
Nerve Laboratory, Neuromuscular
Disease Center, Neurological Institute,
Cleveland Clinic
Small fiber neuropathy:
A burning problem
■ ■ABSTRACT
Small fiber neuropathy is increasingly being recognized
as a major cause of painful burning sensations in the
feet, especially in the elderly. Although strength remains
preserved throughout the course of the disease, the
pain and paresthesias are often disabling. Diabetes
mellitus is the most common identifiable cause of small
fiber neuropathy, and impaired oral glucose tolerance
and individual components of the metabolic syndrome
are often associated with it. Some cases, however, are
idiopathic. Skin biopsy (with an evaluation of the density
of intraepidermal nerve fibers) and tests of autonomic
nerve function are useful for the diagnosis. Management
involves controlling pain and identifying and aggressively treating the underlying cause.
■ ■KEY POINTS
Symptoms of small fiber neuropathy typically start with
burning feet and numb toes.
Causes and associated conditions can be found in over
50% of cases. These include glucose dysmetabolism,
connective tissue diseases, sarcoidosis, dysthyroidism,
vitamin B12 deficiency, paraproteinemia, human immunodeficiency virus infection, celiac disease, neurotoxic drug
exposure, and paraneoplastic syndrome.
Findings on routine nerve conduction studies and
electro­­myography are typically normal in this disease.
Management includes aggressively identifying and treating the underlying cause, advising lifestyle modifications,
and alleviating pain.
doi:10.3949/ccjm.76a.08070
n estimated 15 to 20 million people in the
A
United States over age 40 have some type
of peripheral neuropathy. In many, the impair1
ment is purely or predominantly in small nerve
fibers, and the clinical presentation consists
of pain, burning, tingling, and numbness in a
length-dependent or stocking-glove distribution. (“Length” refers to distance from the trunk;
distal fibers are affected first.) Symptoms typically begin in the feet and slowly ascend to the
distal legs, at which point the hands may also be
affected (FIGURE 1).
In many of these patients, the findings on
neurologic examination, nerve conduction studies, and electromyography are normal, although
some may show signs of mild distal sensory loss
on physical examination. The lack of objective
findings on routine nerve conduction studies and
electromyography may lead many physicians to
attribute the symptoms to other disorders such as
plantar fasciitis, vascular insufficiency, or degenerative lumbosacral spine disease.
The past 2 decades have seen the development of specialized tests that have greatly
facilitated the diagnosis of small fiber neuropathy; these include skin biopsy to evaluate the
density of nerve fibers in the epidermis and
studies of autonomic nerve function. Common etiologies have been identified for small
fiber neuropathy and can be specifically treated, which is critical for controlling progression
of the disease. Pain management is becoming
easier with more available options but is still
quite challenging.
■■ WHAT IS Small fiber NEUROPATHY?
Small fiber neuropathy is a disorder of the peripheral nerves that primarily or exclusively
CL EVE L AND CL I NI C J O URNAL O F M E DI CI NE V O L UM E 76 • NUM BE R 5 M AY 2009 297
Small fiber neuropathy
tive impairment of small myelinated A-delta
and unmyelinated C fibers.
Small fiber
neuropathy is
often mistaken
for plantar
fasciitis,
vascular
insufficiency, or
degenerative
lumbosacral
spine disease
298 FIGURE 1. Symptoms are pain, burning,
numbness, and autonomic dysfunction (lack
of sweating) in the hands and feet in a
stocking-glove distribution. Strength is not
affected. Tendon reflexes are normal, as are
nerve conduction studies.
affects small somatic fibers, autonomic fibers,
or both, resulting in sensory changes and autonomic dysfunction when both types are involved (FIGURE 2).2
Peripheral nerve fibers can be classified according to size, which correlates with the degree of myelination.
• Large nerve fibers are heavily myelinated
and include A-alpha fibers, which mediate
motor strength, and A-beta fibers, which
mediate vibratory and touch sensation.
• Medium-sized fibers, known as A-gamma
fibers, are also myelinated and carry information to muscle spindles.
• Small fibers include myelinated A-delta fibers and unmyelinated C fibers, which innervate skin (somatic fibers) and involuntary muscles, including cardiac and smooth
muscles (autonomic fibers). Together, they
mediate pain, thermal sensation, and autonomic function.
Small fiber neuropathy results from selec-
Sensory symptoms:
Pain, burning, tingling, numbness
Damage to or loss of small somatic nerve fibers
results in pain, burning, tingling, or numbness
that typically affects the limbs in a distal-toproximal gradient. In rare cases, small fiber
neuropathy follows a non-length-dependent
distribution in which symptoms may be manifested predominantly in the arms, face, or
trunk.
Symptoms may be mild initially, with some
patients complaining of vague discomfort in
one or both feet similar to the sensation of a
sock gathering at the end of a shoe. Others
report a wooden quality in their feet, numbness in their toes, or a feeling as if they are
walking on pebbles, sand, or golf balls. The
most bother­some and fairly typical symptom
is burning pain in the feet that extends proximally in a stocking-glove distribution and
is often accompanied by stabbing or aching
pains, electric shock-like or pins-and-needles
sensations, or cramping of the feet and calves.
Symptoms are usually worse at night and
often affect sleep. Some patients say that their
feet have become so exquisitely tender that they
cannot bear having the bed sheets touch them,
and so they sleep with their feet uncovered. A
small number of patients do not have pain but
report a feeling of tightness and swelling in their
feet (even though the feet appear normal).
Examination often reveals allodynia (perception of nonpainful stimuli as being painful), hyperalgesia (perception of painful stimuli as being more painful than expected), or
reduced pinprick and thermal sensation in
the affected area. Vibratory sensation can be
mildly reduced at the toes. Motor strength,
tendon reflexes, and proprioception, however,
are preserved because they are functions of
large nerve fibers.
Autonomic symptoms
When autonomic fibers are affected, patients
may experience dry eyes, dry mouth, ortho­
static dizziness, constipation, bladder incontinence, sexual dysfunction, trouble sweating,
or red or white skin discoloration.2 Examination may show orthostatic hypotension and
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TAVEE AND ZHOU
MM Small fiber neuropathy affects sensory nerves
Small fiber neuropathy is a major cause of pain in the hands and feet, especially in the elderly.
Diabetes mellitus is the most common identifiable cause, but there are many others. The affected
nerve fibers are the small-diameter myelinated A-delta fibers and unmyelinated C fibers, which mediate
pain, thermal sensation, and autonomic function. Large fibers that innervate muscles are not affected.
Skin biopsy may show a paucity of nerve fibers. Quantitative
sudomotor axon reflex testing may show a lack of sweatNerve
ing in response to acetylcholine.
endings
Epidermis
Dermis
Spinal cord
Dorsal root ganglion
Sweat
gland
Subcutaneous
layer
Small fiber
nerve (sensory)
Skin
Medical Illustrator:
Joseph Kanasz
CCF
©2009
Normal skin biopsySmall fiber neuropathy biopsy
Normal innervation with small nerve fibers seen in
the epidermis (arrows). Skin biopsy specimens with
protein gene product 9.5 immunostaining.
A specimen from a patient with small fiber neuropathy shows denervation with no small nerve fibers
seen in the epidermis.
FIGURE 2
CL EVE L AND CL I NI C J O URNAL O F M E DI CI NE V O L UM E 76 • NUM BE R 5 M AY 2009 299
Small fiber neuropathy
skin changes. The skin over the affected area
may appear atrophic, dry, shiny, discolored, or
mildly edematous as the result of sudomotor
and vasomotor abnormalities.
■■ WHAT CAUSES
Small fiber neuropathy?
Small fiber neuropathy has been associated with
many medical conditions, including glucose
dysmetabolism,3 connective tissue disease,4,5
dysthyroidism,6 vitamin B12 deficiency, paraproteinemia, human immunodeficiency virus
(HIV) infection,7 hepatitis C virus infection,
celiac disease,8 restless legs syndrome,9 neurotoxic drug exposure, hereditary diseases, and
paraneoplastic syndrome. While most of these
conditions cause a length-dependent small fiber neuropathy, others (Sjögren disease, celiac
disease, and paraneoplastic syndrome) can
cause a form of small fiber neuropathy that is
not length-dependent.4,8,10
The most
bothersome
symptom is
burning pain
in the feet
that extends
proximally in a
stocking-glove
distribution
300 Diabetes and prediabetes
Glucose dysmetabolism, including diabetes
and prediabetes with impaired oral glucose
tolerance (a glucose level 140–199 mg/dL 2
hours after a 75-g oral dextrose load), is the
most common identifiable associated condition, present in about one-third of patients
with painful sensory neuropathy11 and in
nearly half of those with otherwise idiopathic
small fiber neuropathy.12–14
Research findings strongly suggest that
even prediabetes is a risk factor for small fiber
neuropathy, and that so-called “impaired glucose tolerance neuropathy” may represent the
earliest stage of diabetic neuropathy. Several
recent studies have found a high prevalence
of impaired glucose tolerance in patients with
sensory peripheral neuropathy,12–14 with a rate
of up to 42% in cases initially thought to be idiopathic14 compared with 14% in the general
population.15 Also, a dose-response relationship between the severity of hyperglycemia
and the degree of neuropathy was demonstrated in one study, in which patients with impaired glucose tolerance more often had small
fiber neuropathy, whereas those with diabetes
more often had polyneuropathy involving
both small and large fibers.14 And studies in
animals and cell cultures have shown that in-
termittent hyperglycemia, which can be seen
in patients with impaired glucose tolerance,
caused sensory neuron and nerve fiber damage and increased spontaneous C-fiber firing,
resulting in neuropathic pain.8,16,17
Metabolic syndrome
Insulin resistance with prediabetes and diabetes is a part of the metabolic syndrome, which
also consists of hypertension, hyperlipidemia,
and obesity. The individual components of
the metabolic syndrome have been implicated
as risk factors not only for cardiovascular and
cerebrovascular disease but also for small fiber
neuropathy.
One study in 548 patients with type 2 diabetes showed that those with the metabolic
syndrome were twice as likely to have neuropathy as those without.18 Another study showed
that in 1,200 patients with type 1 diabetes
without neuropathy at baseline, hypertension,
hyperlipidemia, and increased body mass index were each independently associated with
a higher risk of developing neuropathy.19
A recent study of 219 patients with idiopathic distal symmetrical peripheral neuropathy and 175 diabetic patients without
neuropathy found a higher prevalence of metabolic syndrome in patients with neuropathy
than in normal populations. The prevalence
of dyslipidemia (high levels of total and lowdensity lipoprotein cholesterol and triglycerides and low levels of high-density lipoprotein
cholesterol), but not hypertension or obesity,
was higher in patients with neuropathy than
in patients with diabetes but no neuropathy.20
The findings linked dyslipidemia to neuropathy and showed the need for further studies of
the potential pathogenic role of dyslipidemia
in neuropathy.
Hereditary causes
Hereditary causes of small fiber neuropathy are
rare and include Fabry disease, Tangier disease,
hereditary sensory autonomic neuropathy, and
hereditary amyloidosis.
■■ HOW DO you EVALUATE PATIENTS WITH
SUSPECTED small fiber neuropathy?
A thorough history should be taken to obtain
details regarding onset and features of neu-
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TAVEE AND ZHOU
ropathy symptoms, exacerbating factors, and
progression. It is also important to ascertain
whether the patient has any associated conditions as mentioned above, a family history of
neuropathy, risk factors for HIV or hepatitis C
virus infection, or a history of neurotoxic drug
exposure.
Clinical suspicion of small fiber neuropathy should be high if a patient presents with
predominant small fiber symptoms and signs
with preserved large fiber functions.
Nerve conduction studies
and electromyography
For diagnostic testing, routine nerve conduction studies and electromyography assess the
function of large nerve fibers only and are thus
normal in small fiber neuropathy. These tests
should still be ordered to rule out subclinical involvement of large fibers, which may
affect the diagnostic evaluation, prognosis,
and treatment plan. However, if the results of
these tests are normal, specialized studies are
needed to evaluate small fibers.
Although several tests are available to
evaluate somatic and autonomic small fibers,
the two that have the highest diagnostic efficiency for small fiber neuropathy and that
are used most often are skin biopsy, to evaluate intra­epidermal nerve fiber density, and
quantitative sudomotor axon reflex testing
(QSART), to assess sudomotor autonomic
function.21–23
Skin biopsy
Skin biopsy is a minimally invasive procedure in which 3-mm-diameter punch biopsy
specimens are taken from the distal leg, distal
thigh, and proximal thigh of one lower limb.
The procedure takes only 10 to 15 minutes.
Biopsy specimens are immunostained using an antibody against protein gene product
9.5, which is a panaxonal marker. Small nerve
fibers in the epidermis are counted under a
microscope, and intraepithelial nerve fiber
densities are calculated and compared with
established normative values. The diagnosis
of small fiber neuropathy can be established if
the intraepidermal nerve fiber density is lower
than normal (FIGURE 1). Nerve fiber density may
be normal in the early stage of small fiber neuropathy, but in this setting skin biopsy often
shows abnormal morphologic changes in the
small fibers, especially large swellings,24 and
repeat biopsy in 6 to 12 months may be considered.
The diagnostic efficiency of skin biopsy
is about 88%.21,23 For diagnosing small fiber
neuropathy, it is more sensitive than quantitative sensory testing21,25 and more sensitive and
less invasive than sural nerve biopsy.26 Intraepidermal nerve fiber density also correlates
well with a variety of measures of severity of
HIV distal sensory neuropathy and thus may
be used to measure the severity and treatment
response of small fiber neuropathy.27
Quantitative sudomotor axon reflex testing
QSART is an autonomic study that measures
sweat output in response to acetylcholine,
which reflects the function of postganglionic sympathetic unmyelinated sudomotor
nerve fibers. Electrodes are placed on the
arms and legs to record the volume of sweat
produced by acetylcholine iontophoresis, in
which a mild electrical stimulation on the
skin allows acetylcholine to stimulate the
sweat glands. The output is compared with
normative values.
One prospective study showed that 67
(72.8%) of 92 patients with painful feet had
abnormal results on QSART, ie, low sweat
output.28 A retrospective study found that 77
(62%) of 125 patients with clinical features of
distal small fiber neuropathy had a length-dependent pattern of QSART abnormalities.22
QSART abnormalities were detected in some
patients without autonomic symptoms.
Nerve
conduction
studies assess
large fibers
only
If these tests are not available
Skin biopsy and QSART are objective, reproducible, sensitive, and complementary in
diagnosing small fiber neuropathy. One or
both can be ordered, depending on whether
the patient has somatic symptoms, autonomic
symptoms, or both. However, these two tests
are not widely available. Only a few laboratories in the country can process skin biopsy
specimens to evaluate intraepidermal nerve
fiber density. Nevertheless, it is easy to learn
the skin punch biopsy procedure, and primary
care physicians and neurologists can perform
it after appropriate training. (A concern is
avoiding damage to the epidermis.) They can
CL EVE L AND CL I NI C J O URNAL O F M E DI CI NE V O L UM E 76 • NUM BE R 5 M AY 2009 301
Small fiber neuropathy
TABLE 1
Drugs for pain control in small fiber neuropathy
drug
Dosage (per day)
Antidepressants
Common side effects
Sedation, weight gain, anticholinergic effects,
sexual dysfunction, arrhythmia
(side effects most prominent with amitriptyline)
Amitriptyline (Elavil)
20–150 mg
Nortriptyline (Aventyl)
20–150 mg
Desipramine (Norpramin)
20–200 mg
Duloxetine (Cymbalta)
60–120 mg
Anticonvulsants
Gabapentin (Neurontin)
600–3,600 mg
Sedation, dizziness, peripheral edema, weight gain
Pregabalin (Lyrica)
150–600 mg
Similar to gabapentin
Topiramate (Topamax)
25–400 mg
Weight loss, sedation, cognitive slowing,
renal stones, paresthesias
Lamotrigine (Lamictal)
25–400 mg
Stevens-Johnson syndrome, rash, dizziness, nausea,
sedation
Carbamazepine (Tegretol)
200–1,200 mg
Dizziness, sedation, ataxia, aplastic anemia,
liver enzyme elevation
Oxcarbazepine (Trileptal)
600–2,400 mg
Dizziness, nausea, fatigue, leukopenia
Topical anesthetics
5% Lidocaine patch (Lidoderm)
Every 12 hours
Local edema, burning, erythema
0.075% Capsaicin patch
Three or four times a day
Burning
Opioids, opioid agonists
Tramadol (Ultram)
100–400 mg
Sedation, dizziness, seizures, nausea, constipation
Oxycodone (Oxycontin)
10–100 mg
Sedation, constipation, nausea;
potential for addiction and abuse
then send specimens to one of the cutaneous
nerve laboratories (but not to a routine reference laboratory).
A special technique, including unique fixative and cryoprotectant, is used to fix and process the biopsy specimens, because routine techniques for processing dermatologic punch biopsy
specimens often result in lower intraepidermal
nerve fiber densities. Therefore, it is very important to contact the laboratory regarding fixative
and processing before performing a biopsy.
QSART requires specialized equipment
and must be performed on site. In addition,
the test is very sensitive to drugs that can affect sweating, such as antihistamines and an-
302 tidepressants, and such drugs must be discontinued 48 hours before the study.
Basic laboratory tests to find the cause
Once the diagnosis of small fiber neuropathy
is established, the next important step is to order a battery of laboratory tests to search for
an underlying cause. The tests should include
the following:
• Complete blood cell count
• Comprehensive metabolic panel
• Lipid panel
• Erythrocyte sedimentation rate
• Thyroid-stimulating hormone level
• Free thyroxine (T4) level
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TAVEE AND ZHOU
• Antinuclear antibody
• Extractable nuclear antigens
• Angiotensin-converting enzyme (ACE) level
• Serum and urine immunofixation tests
• Vitamin B12 level
• 2-hour oral glucose tolerance test.
Oral glucose tolerance testing is much more
sensitive than measuring the hemoglobin A1c
and fasting glucose levels in detecting diabetes
and prediabetes. These two conditions were
detected by oral glucose tolerance testing in
more than 50% of patients with otherwise
idiopathic sensory-predominant peripheral
neuropathy and normal hemoglobin A1c and
fasting glucose levels.13,14 Therefore, every
patient with small fiber neuropathy without
a known history of diabetes or prediabetes
should have an oral glucose tolerance test.
Special laboratory tests in special cases
• If there is a history of gastrointestinal symptoms or herpetiform-like rash, then testing for
gliadin antibody and tissue transglutaminase
antibodies as well as small-bowel biopsy may
be pursued to evaluate for celiac sprue.
• Serologic tests for HIV or hepatitis C should
be ordered if the patient has risk factors.
• If there is a significant family history, further genetic testing should be considered.
• Lip biopsy or bone marrow biopsy should
be considered if clinical suspicion is high for
Sjögren disease, seronegative sicca syndrome,
or amyloidosis.
• The serum ACE level has a low sensitivity
and specificity; therefore, if sarcoid is suspected
clinically, additional confirmatory testing, such
as computed tomography of the chest, should
be ordered despite a normal ACE value.
■■ HOW DO YOU TREAT
Small fiber neuropathy?
Treatment of small fiber neuropathy should
target the underlying cause and neuropathic
pain. Cause-specific treatment is a key in preventing small fiber neuropathy or slowing its
progression.
Glucose control, weight control,
and regular exercise
As glucose dysmetabolism is the condition
most often associated with small fiber neu-
ropathy (and since individual components
of the metabolic syndrome are potential
risk factors for it), tight glycemic control
and lifestyle modification with diet control,
weight control, and regular exercise are of
paramount importance in patients with these
conditions.
The Diabetic Prevention Program,29 a
study in 3,234 people with prediabetes, found
that diet and exercise were more effective
than metformin (Glucophage) in preventing full-blown diabetes. At an average of 2.8
years of follow-up, the incidence of diabetes
was 11.0 cases per 100 patient-years in a group
assigned to receive placebo, compared with
7.8 in those assigned to receive metformin
(31% lower), and 4.8 (58% lower) in those
who were assigned to undergo a lifestyle intervention that included at least 150 minutes
of physical activity per week with a weightloss goal of 7%. Put another way, to prevent
one case of diabetes over 3 years, 6.9 patients
would have to undergo the lifestyle intervention program, or 13.9 would have to receive
metformin. Since impaired glucose tolerance
neuropathy may represent the earliest stage of
diabetic neuropathy, the neuropathy at this
stage may be reversible with lifestyle intervention and improvement of impaired glucose tolerance.
This concept is supported by a 3-year study
in 31 people, which showed that lifestyle intervention significantly improved impaired
glucose tolerance, reduced the body mass
index, and lowered total serum cholesterol
levels.30 Changes in these metabolic variables
were accompanied by significant improvement of neuropathy as evidenced by significantly increased intraepidermal nerve fiber
density, increased foot sweat volume, and decreased neuropathic pain.30
Only a few
cutaneous
nerve laboratories can process
skin biopsy
specimens to
evaluate
intraepidermal
nerve fiber
density
Treatment of other diseases
It has also been reported that treatment
of sarcoidosis, autoimmune diseases, and
celiac disease improved the symptoms of
small fiber neuropathy resulting from these
conditions.8,31 Therefore, it is important to
identify the cause and treat it to prevent and
slow the progression of small fiber neuropathy, and doing so may improve the disease in
some mild cases.
CL EVE L AND CL I NI C J O URNAL O F M E DI CI NE V O L UM E 76 • NUM BE R 5 M AY 2009 303
Small fiber neuropathy
Pain management
Pain management is crucial in the treatment
of small fiber neuropathy, as neuropathic pain
can be debilitating and can cause depression.
Pain management often requires a multidisciplinary team, including a primary care physician, a neurologist, a pain specialist, and a psychiatrist. Medications include antidepressants,
anticonvulsants, and topical anesthetics (TABLE
1) as well as narcotic and non-narcotic analgesics and antiarrhythmics. Nonpharmacologic
management includes transcutaneous electrical nerve stimulation (TENS), heat, ice, and
massage of painful areas (reviewed by Chen et
al32 and Galluzzi33).
First-line choices of pain medications are
the anticonvulsants gabapentin (Neurontin)
and pregabalin (Lyrica), the tricyclic antidepressants amitriptyline (Elavil) and nortriptyline (Aventyl), a 5% lidocaine patch (Lidoderm), and the semisynthetic opioid analgesic
tramadol (Ultram). These can be used alone
or in combination.
Gabapentin is relatively well tolerated,
but drowsiness can occur, especially with high
starting doses. We usually start with 300 mg
daily and increase it by 300 mg every week
All patients
up to 1,200 mg three times a day as tolerated.
with small fiber Most patients need 600 to 900 mg three times
a day.
neuropathy
Pregabalin is a newer antiepileptic drug,
without known similar to gabapentin but less sedating. It can
started at 75 mg twice a day and gradually
diabetes or pre- be
increased to 300 mg twice a day as needed.
diabetes need Weight gain and, rarely, swelling of the lower
an oral glucose extremities may limit the use of both of these
drugs.
tolerance test Tricyclic antidepressants, such as amitriptyline, nortriptyline, and desipramine (Norpramin), are proven effective in controlling
neuropathic pain, although no response with
amitriptyline was seen in patients with painful
HIV distal sensory neuropathy.34
Lidocaine patch is preferred if the painful area is small. Patients should be instructed
to use the patch to cover the painful area 12
hours on and 12 hours off. If it does not provide relief within 1 week, it should be discontinued.
Tramadol is also helpful in treating neuropathic pain. It can be started at 50 mg two to
four times a day as needed.
304 Nonsteroidal anti-inflammatory drugs
and selective serotonin reuptake inhibitors
are typically less effective than the other drugs
mentioned.
Opioids should be reserved for refractory
cases, given the potential for addiction, but
they are sometimes necessary in patients with
disabling pain that does not respond to other
drugs.
TENS may be of benefit. The patient controls a pocket-size device that sends electrical
signals to leads placed on affected areas.
Alternative therapies for small fiber neuropathy, such as meditation, yoga, and acupuncture, have yet to be studied.
It is also important to explain to patients
that the typical course of small fiber neuropathy is relatively benign, as many patients
worry about developing weakness and eventually not being able to walk. These concerns
and fears can aggravate pain and depression,
which can make treatment difficult.
■■ WHAT IS THE PROGNOSIS
OF small fiber neuropathy?
Most patients with small fiber neuropathy
experience a slowly progressive course, with
symptoms and signs spreading proximally over
time.
In one study, only 13% of 124 patients
with small fiber neuropathy showed evidence
of large-fiber involvement over a 2-year period.21 None went on to develop Charcot joints,
foot ulcers, weakness, or sensory ataxia, as is
often seen in patients with long-standing or
severe large fiber neuropathy. Neuropathic
pain worsened in 30% and resolved spontaneously in 11%.21
Most patients with small fiber neuropathy
require chronic pain management. Again,
treatment of the underlying cause is important
and can improve the prognosis.
We believe that the overall progression of
small fiber neuropathy is slow. A longitudinal
study with a follow-up longer than 2 years
would be useful to confirm this.
■■ take-home points
As the population continues to age and as
more patients develop diabetes and the meta-
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TAVEE AND ZHOU
bolic syndrome, the prevalence of small fiber
neuropathy will rise. Patients who present to
their primary care physicians with painful,
burning feet require a thorough diagnostic
evaluation, which may include referral for
specialized neurodiagnostic testing. Aggressive cause-specific treatment, lifestyle modification, and pain control are key elements
of a team approach to managing small fiber
■
neuropathy.
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ADDRESS: Lan Zhou, MD, PhD, Neuromuscular Disease Center, Neurological Institute, S90, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH
44195; e-mail zhoul2@ccf.org.
CME ANSWERS
Answers to the credit test on page 319 of this issue
1D 2B 3A 4C 5D 6C 7B 8D
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